Anomalous Bronchial Arteries Originating from a Common Bronchial Arterial Trunk Detected by Trans-Esophageal Echocardiography: A Multi-Faceted Imaging Approach

Abstract

A 56-year-old male presented to the hospital with fever, chills and malaise. His past medical history included; coronary artery disease status post coronary artery bypass graft surgery, chronic severe mitral regurgitation, monoclonal gammopathy of undetermined significance and chronic portal vein thrombosis. Vital signs demonstrated a blood pressure of 130/70 mmHg, heart rate of 110 bpm and normal temperature. The physical examination was unremarkable except for an apical pan-systolic murmur. Two sets of blood culture revealed Group B streptococci. A transesophageal echocardiogram (TEE) showed mobile vegetation attached to the mitral valve anterior leaflet with severe mitral regurgitation. Additionally, an abnormal continuous turbulent flow with systolic augmentation was noted posterior to the main pulmonary artery trunk. The Peak systolic velocity of this jet was 1.8-2.0 m/s. The high aliasing velocity, the spectral Doppler profile and flow proximity to pulmonary trunk were consistent with an aortic origin of the flow. A cardiac CT angiogram revealed a completely occluded venous graft to the right coronary artery and a patent graft to the obtuse marginal branch. An incidental finding was an anomalous common bronchial artery (BA) trunk arising from the proximal descending thoracic aorta. It gave rise to a large, tortuous right and small left BA. To the best of our knowledge this is the first case report of an anomalous BA detected by TEE. In our patient, two mechanisms may explain the extensive dilatation and tortuosity of the BA system: increased left atrial pressure from chronic severe mitral regurgitation and chronic pulmonary hypertension